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NEW evidence that optimism can improve patient outcomes has sparked debate about whether doctors should withhold bad news from patients.
Research in Archives of Internal Medicine found that heart disease patients with higher expectations about their future lifestyle and prognosis had better functioning and survival over a 15-year follow-up. (1)
In a related editorial, Dr Robert Gramling and Dr Ronald Epstein, of the University of Rochester in New York, said the research adds to a “compelling body of evidence” showing that optimism for future heart health is associated with cardiovascular benefits. (2)
They suggest that this growing evidence could lead physicians to actively promote optimism, or even conceal negative information from patients.
“We might even consider ourselves ethically justified in withholding or obfuscating poor prognoses from patients,” they write.
However, Professor Martin Tattersall, professor of medicine at the University of Sydney, said there were other ways to sustain hope without lying or avoiding the discussion.
“There are hope-giving ways of talking about prognosis, and one of the least hope-giving ways is not to talk about it,” said Professor Tattersall, who has written extensively on communicating prognoses with patients. (3,4)
Carol Bennett, CEO of the Consumers Health Forum of Australia, said that withholding information from patients was “highly unethical” and disrespectful.
“How can you foster a relationship based on good communication and collaboration when one party is playing god and deciding what information a consumer should have?”
Ms Bennett agreed that optimism could be useful, but she said that withholding information removed the patient’s ability to take control to improve their health care.
Professor Tattersall recommended that to promote hope, clinicians could describe the best-case, worst-case and typical survival scenarios to patients, rather than focussing on the median survival time.
“Sustain the uncertainty … uncertainty is, in fact, hope-giving, but providing patients with just one number is the exact opposite,” he said.
He agreed with the editorial that optimism and realism can coexist, such that patients may hope for a miracle while acknowledging it might not happen.
The editorial writers used Captain Kirk and Commander Spock from Star Trek to illustrate the point that people often use optimism in the “face of less-than-optimistic evidence”.
“Is it the hyperrational, unemotional Spock whom we emulate? ‘Captain, the statistical likelihood that our plan will succeed is less than 4.3 percent.’ Or are we drawn to the ever-optimistic (and usually correct) Captain Kirk? ‘Spock, it will work.’ Well, when it comes to our hearts, we generally aspire to Captain Kirk,” the editorial said.
Although hope has been linked to improved outcomes, it also had a dark side. The editorial cautioned that unbridled optimism may leave patients devastated when reality set in, and could encourage patients to take on “burdensome treatments”.
Professor Tattersall agreed that extreme optimism could be harmful.
“What’s been shown in oncology is that if you think your prognosis is much better than it actually is, you don’t live longer but actually have a worse death, with more treatments and ICU admissions,” he said.
– Sophie McNamara
1. Arch Intern Med 2011; 171: 929-935
2. Arch Intern Med 2011; 171: 935-936
Posted 30 May 2011
I have recently lost my brave husband to an angiosarcoma of the sacrum. My husband was a healthy ,active 39 year old man who loved life. Professor Tattersall treated him from early December and he lost his battle a few weeks ago. We also met the very well known surgeon and although yes he was extremely blunt , looking back now I can sympathise with his manner as the harsh reality of this horrid disease necessitated such brutality. This is not to say that Professor’s continuous positiveness was not appreciated. It was needed as this silent killer of a disease took hold of my dear husband and made him deterioate in just three weeks before his body could fight no longer.
I feel I need to thank Professor for his true optimism but feel conflicted by the ‘Always treat on the bright side ‘ approach because maybe my husband was given too much hope ? Can you give someone too much hope ? I really do not know anymore as I have lost an amazing man , loving husband and dedicated father to my three children. I do know this , I am truly thankful for everyone’s effort in trying to cure my husband, from the nurses to the registrars and of course the incomparable Professor Martin Tattersall. Royal Prince Alfred hospital has a special place in my broken heart as it was a second home to us the last eight months of my husband’s life. The memories of the necessary horrendous treatments will be remembered along with the special lunches we would have at the cafe up the road whilst waiting for chemo to be ready.
For those who are fighting this disease , don’t ever give up. Fight. Fight every day and know that your doctors and the nurses will keep on fighting too.
Prof. Tattersall is my oncologist and is currently treating my qsteosarcoma. He is quite frank while talking about my cancer and, as he said, discusses about the best and worst case scenarios and what further steps would be in both the cases. In many occasions his attitude has helped me stay positive when the surgeons were quite blunt in the way they talk and answered my questions. The day they confirmed it was a sarcoma, the surgeon told me, “you will die if you do not start chemotherapy straight away and you will be seeing me for next 5 years”. Now, for someone with zero knowledge of cancer and chemo, I got freaked out. But on the next appointment with Prof. Tattersall, he was quite nice to explain a lot about the history of sarcomas, advancements in treatment, possible prognosis in a much calmer and coordinated way. Really lifted up my morale and took me in a positive direction.
The surgeon is one of the best in the country but still was quite blunt in all of my other visits as well. Probably its his way but his appointments made me a lot more anxious and put me in lot of fear mentally.
If I had to err, I would rather err on the positive side.
A wife tells the family doctor; “If it is cancer, please don’t tell my husband, he will not be able to cope.” So the doctor when finding out that it was stomach cancer, tells the man; “The findings show that you have a stomach problem, take this medication it will help you.” The cancer went away. This type of thing is not an isolated case. Who are we to shell out doom and gloom that may hasten death? There is more and more evidence about the placebo, as well as the nosebo effect. So would it be fair to comment that we could be playing God by telling them a negative prognosis and stunt their inner healing power? I know of two people in my life that were given a “Go home and write your will, there is nothing more that we can do for you.” One is now 15 years down the track, the other is over 20 years down the track. Luckily, they were of the mind to prove their diagnosis wrong.
As a practitioner who deals with people at the other end of the spectrum, counselling and psychotherapy, I would like to say that the statistics in this area do back Professor Tattersall’s comments.
There is also the large problem, from patients’ perspective, of too many members of the medical team being either unaware or unheeding of the negative effects of both bluntness and presumptiousness in how an individual will deal with the remaining time they have.
As a precutionary tale let me speak of a psychotherapy client who had end-stage pancreatic cancer… He was functioning well, considering his prognosis, pain free and enjoying his family time. Until a blunt comment on his happy mood.
“Haven’t you accepted that you are going to die yet”
I TRULY WISH THE DOCTOR WHO MADE THE COMMENT HAD BEEN THERE TO SEE THIS ACCEPTING CONTENT MAN WITHDRAW FROM HIS FAMILY AND THE WORLD INTO HIS OWN SHELL. TO JUST GIVE UP, CURL UP AND DIE WITHIN 2 DAYS!
Although most medical practitioners and staff are far more considerate and caring than that, this, as we know, has been far from an isolated incident. So please be very cautious of how and what you say.
This interesting study raises another question for me: Could it be that state of mind is yet another clinical indicator?
It sounds like these patients were, to some extent, correct in having positive or negative expectations of their outcomes. There is a known association between depression and cardiovascular disease. Maybe that patient, like the customer, knows best after all.